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DOTS
By JONATHAN ABISH DAVID
2nd year MBBS
TUBERCULOSIS
TB is caused by Mycobacterium tuberculosis
TB can affect any organ system: bone, kidney, CNS;
80% are pulmo...
SYMPTOMS OF TUBERCULOSIS
NIGHT SWEATS COUGH 2+WEEKS
LOSS OF
APPETITE
FEVER
WEIGHT
LOSS
FATIGUE
TB: A Global Emergency
1/3 of the world (2 billion people) infected
1 person infected/second resulting in >30 million
ne...
Problem of TB in India
 Estimated incidence
 1.96 million new cases annually
 0.8 million new smear positive cases annu...
ANTI- TB DRUGS
FIRST LINE SECOND LINE
ISONIAZID THIOACETAZONE
RIFAMPICIN PAS
PYRAZINAMIDE ETHIONAMIDE
ETHAMBUTOL CYCLOSERI...
WHAT IS DOTS
Directly Observed Therapy Shortcourse is a
program to help cure TB.
A DOT Lay Worker meets with clients to ...
Directly Observed Treatment Shortcourse
 Why? Many patients don’t take medicines regularly, even if excellent
health educ...
DIRECT OBSERVED
TREATMENT
SHORTCOURSE(DOTS)
INTENSIVE PHASE
( 2-3 months)
UNDER DIRECT
SUPERVISION OF A
HEALTH WORKER OR
T...
Global Situation
Since 1995,over 21 million patients have been
diagnosed and treated in DOTS programmes
In 2007, 5.5 mil...
DOTS Regimen
Category Type of Patient Regimen Duration
in
months
Category I
Color of
box: RED
New Sputum Smear Positive
Ne...
Contd.
Category Type of Patient Regimen Durat
ion in
mont
hs
Category III
Color of box:
GREEN
Sputum Negative,
extra pulmo...
DRUG DOSE
ISONIAZID 600 mg
RIFAMPICIN 450 mg
PYRAZINAMIDE 1500 mg
ETHAMBUTOL 1200 mg
STREPTOMYCIN 750 mg
DOSAGE
MULTI DRUG RESISTANT TB (MDR-TB)
ATLEAST RESISTANT TO ISONIAZID AND RIFAMPICIN
TREATMENT BASED ON DOTS – PLUS
DOTS- PLUS
I...
EXTENSIVELY DRUG RESISTANT TB (XDR
TB)
Resistance to Isoniazid and Rifampicin + resistance
to any of the Fluoroquinolones...
EXTREMELY DRUG RESISTANT TB (XDR TB)
INTENSE PHASE
(6-12 months)
 Caperomycin
 PAS
 Moxifloxacine
 Clofazimine
 Linez...
DURING PREGNANCY
The drugs Streptomycin, Fluoroquinolones,
Ethionamide, Protionamide are avoided
DOSAGE FOR CHILDREN
DRUGS
Isoniazid
Rifampicin
Pyrizinamide
Ethambutol
streptomycin
THERAPHY PER DOSE
(THRICE A WEEK)...
Advantages of DOTS
 The client is supported to successfully complete the full
course of medication.
 The client is monit...
Adverse reactions to anti-TB drugs
Drugs
Isoniazid
Rifampicin
pyrazinamide
Adverse effects
 Peripheral neuropathy
 He...
Drugs
Ethambutol
streptomycin
Adverse effects
Optic neuritis
Renal damage
Auditory &
vestibular nerve
damage
2015
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  1. 1. DOTS By JONATHAN ABISH DAVID 2nd year MBBS
  2. 2. TUBERCULOSIS TB is caused by Mycobacterium tuberculosis TB can affect any organ system: bone, kidney, CNS; 80% are pulmonary
  3. 3. SYMPTOMS OF TUBERCULOSIS NIGHT SWEATS COUGH 2+WEEKS LOSS OF APPETITE FEVER WEIGHT LOSS FATIGUE
  4. 4. TB: A Global Emergency 1/3 of the world (2 billion people) infected 1 person infected/second resulting in >30 million new infections, 8 million new cases Left untreated 1/3 die, 1/3 self-cure, 1/3 remain infectious TB kills 1 person every 10 seconds = 5000/day = 2-3 million each year
  5. 5. Problem of TB in India  Estimated incidence  1.96 million new cases annually  0.8 million new smear positive cases annually  75 new smear positive PTB cases/1lakh population per year  Estimated prevalence of TB disease  3.8 million bacillary cases in 2000  1.7 million new smear positive cases in 2000  Estimated mortality  330,000 deaths due to TB each year  Over 1000 deaths a day  2 deaths every 3 minutes
  6. 6. ANTI- TB DRUGS FIRST LINE SECOND LINE ISONIAZID THIOACETAZONE RIFAMPICIN PAS PYRAZINAMIDE ETHIONAMIDE ETHAMBUTOL CYCLOSERINE STREPTOMYCIN KANAMYCIN CAPREOMYCIN AMIKACIN NEWER DRUGS CIPROFLOXACIN OFLOXACIN CLARITHROMYCIN AZITHROMYCIN RIFABUTIN ISONIAZID RIFAMPICIN PYRAZINAMIDE ETHAMBUTOL
  7. 7. WHAT IS DOTS Directly Observed Therapy Shortcourse is a program to help cure TB. A DOT Lay Worker meets with clients to help with TB medication, and provide support and education.  DOT by definition means watching clients swallow each dose of anti-TB medication
  8. 8. Directly Observed Treatment Shortcourse  Why? Many patients don’t take medicines regularly, even if excellent health education provided  Who? All patients... impossible to predict which patient will take medicine (1/3 not adherent)  What? Observer watches and helps patient swallow tablets  Where? Anywhere! (home, clinic, work, school, etc)  Who does it? HCW, community liaisons, teachers, Direct observation ensures treatment for entire course with the right drugs, in the right doses, at the right intervals
  9. 9. DIRECT OBSERVED TREATMENT SHORTCOURSE(DOTS) INTENSIVE PHASE ( 2-3 months) UNDER DIRECT SUPERVISION OF A HEALTH WORKER OR TRAINED PERSON CONTINUATION PHASE (4-6 months) A MULTIBLISTER COMBIPACK WITH DRUGS FOR 1 WEEK IS GIVEN OF WHICH THE FIRST DOSE IS TAKEN UNDER SUPERVISION
  10. 10. Global Situation Since 1995,over 21 million patients have been diagnosed and treated in DOTS programmes In 2007, 5.5 million new and relapse TB cases were initiated on treatment under DOTS strategy Of 2.5 million new smear positive patients registered in 2006, 85% were successfully treated under DOTS
  11. 11. DOTS Regimen Category Type of Patient Regimen Duration in months Category I Color of box: RED New Sputum Smear Positive New Sputum Smear Negative New Extra Pulmonary New Others 2 (HRZE)3, 4 (HR)3 6 Category II Color of box: BLUE Sputum Positive relapse Sputum Positive failure Sputum Positive treatment after default 2 HRZES)3, 1 (HRZE)3 5 (HRE)3 8 Test at month 2 3 H-ISONIAZID R- RIFAMPICIN Z-PYRAZINAMIDE E- Ethambutol
  12. 12. Contd. Category Type of Patient Regimen Durat ion in mont hs Category III Color of box: GREEN Sputum Negative, extra pulmonary not Seriously ill 2 (HRZ)3, 4 (HR)3 6
  13. 13. DRUG DOSE ISONIAZID 600 mg RIFAMPICIN 450 mg PYRAZINAMIDE 1500 mg ETHAMBUTOL 1200 mg STREPTOMYCIN 750 mg DOSAGE
  14. 14. MULTI DRUG RESISTANT TB (MDR-TB) ATLEAST RESISTANT TO ISONIAZID AND RIFAMPICIN TREATMENT BASED ON DOTS – PLUS DOTS- PLUS INTENSIVE PHASE 6-9 MONTHS KANAMYCIN OFLOXACIN CYCLOSERINE ETHINAMIDE ETHAMBUTOL PYRAZINAMIDE CONTINUATION PHASE 18 MONTHS OFLOXACIN CYCLOSERINE ETHIONAMIDE ETHAMBUTOL
  15. 15. EXTENSIVELY DRUG RESISTANT TB (XDR TB) Resistance to Isoniazid and Rifampicin + resistance to any of the Fluoroquinolones + resistance to any one of the injectible second line drugs
  16. 16. EXTREMELY DRUG RESISTANT TB (XDR TB) INTENSE PHASE (6-12 months)  Caperomycin  PAS  Moxifloxacine  Clofazimine  Linezolid  Amoxicillin / Clavulanate CONTINUATION PHASE (18 months)  PAS  Moxifloxacine  Isoniazid  Clofazimine  Linezolid  Amoxicillin / Clavulanate
  17. 17. DURING PREGNANCY The drugs Streptomycin, Fluoroquinolones, Ethionamide, Protionamide are avoided
  18. 18. DOSAGE FOR CHILDREN DRUGS Isoniazid Rifampicin Pyrizinamide Ethambutol streptomycin THERAPHY PER DOSE (THRICE A WEEK) 10-15 mg/kg 10 mg/kg 35 mg/kg 30 mg/kg 15 mg/kg
  19. 19. Advantages of DOTS  The client is supported to successfully complete the full course of medication.  The client is monitored closely for side effects of medications and supported to work through the side effects appropriately.  The client is encouraged and supported to complete required check ups – blood work, chest x-rays, etc.  Reduces the possibility of tb germs becoming resistant to the medication
  20. 20. Adverse reactions to anti-TB drugs Drugs Isoniazid Rifampicin pyrazinamide Adverse effects  Peripheral neuropathy  Hepatitis  Vomitting , abdominal pain  Hepatitis  Joint pains , hepatitis
  21. 21. Drugs Ethambutol streptomycin Adverse effects Optic neuritis Renal damage Auditory & vestibular nerve damage
  22. 22. 2015

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